Become a KBFitnessOnline.com Member

Here is a short video explaining what information KBFitnessonline.com members will have access to.  Knee conditions include Total Knee Replacement, Patella-Femoral Pain Syndrome, Quadriceps Strain, Hamstring Strain, Shin Splints, Arthroscopic Surgery, ACL Repair, Medial Collateral Ligament Sprain, and topics such as walking with crutches, stair climbing, lifting techniques, pain management, exercise progressions, manual techniques, etc.. You will receive explanatory videos as well as follow along treatment sessions based on rehabilitation protocols.

KBFitnessonline Membership Offer

Check out www.kbfitnessonline.com to become a member today!

Meniscus Arthroscopic Surgery

Many of my patients have undergone arthoscopic surgery for a meniscus tear.  Upon initiating Physical Therapy, they are usually confused as to what the surgery entailed, and do not really know what or where the meniscus actually is.  This video is a good basic explanation of the knee anatomy and surgical procedure. 

Arthroscopy for Meniscus Tear

Become a member of www.kbfitnessonline.com for access to the step-by-step exercise rehabilitation protocol and follow along treatment sessions following your arthroscopic meniscectomy.  You will also gain access to the full knee exercise video library, which will assist in your progression to a Post-Rehab Fitness Program. 

Considerations When Placing Your Client/Patient on a Stationary Bike

Seat Height:
You may initially use a high seat position to allow full pedal revolution. However, this position may not be the most beneficial for clients with ACL injuries/reconstructions or those suffering from Iliotibial Band Syndrome. A low seat position is not advised for those with Patello-Femoral Pain Syndrome (PFPS).
Recumbent Bike or Upright:
There is minimal to no difference in the required Knee ROM to pedal either type. However, there is less load on the ACL using the recumbent bike, so it is advised for ACL patients/clients.
Direction of pedaling:?
Retro or backward pedaling may be used for meniscus conditions and Tibio-Femoral osteoarthritis, but is not advised for ACL or PFPS conditions. Retro-pedaling creates increased stress on the patella-femoral joint due to the increase activity of the quadriceps relative to the hamstrings. Also, when the knee is fully extended in retro-pedaling, the ACL is most vulnerable.
Summary:
For patients/clients with ACL conditions, use a recumbent bike, avoid a high seat position and retro-pedaling.
For patients/clients with Patella-Femoral Pain Syndrome (PFPS), avoid a low seat position as well as retro-pedaling.

For More Blog Articles, Check out: www.kbfitnessonline.com or http://kbfitnessonline.com/blog/

Online Physical Therapy for your Knee Condition

Recently launched, www.kbfitnessonline.com!!  This site provides a member with over 100 educational videos for common knee conditions.  You will receive individual exercises and follow along training routines that will assist you in your rehabilitation and eventual transition to a Post Rehab Fitness Program.    Check it out!!!      KB FITNESS VIDEO

Total Knee Replacement Surgery

Here is a informative video on what is actually being performed during a Total Knee Replacement Surgery.     

Total Knee Replacement Video

Most patients do not know what to expect following Knee Replacement Surgery.  This is a good video explanation:

Information Following Surgery

For information and follow-along Physical Therapy Video Exercise Protocols starting Day 1 following this surgery, go to:  www.kbfitnessonline.com or www.kneepainvideos.com

The Loving Touch Foundation

The Power of Touch!  I was able to learn these Infant Massage Techniques from Diana Moore prior to the birth of my first son, and found it to be very helpful for colic, relaxation and parent-child bonding.  Click below for more information on Infant Massage and the Loving Touch Foundation's efforts in helping children who receive little or even no tactile stimulation in the Romanian Orphanages. 

INFANT MASSAGE - LOVING TOUCH

Kinesiotaping Very Popular With Athletes

Each year, we see it being used more frequently by athletes.  I've used it on many people suffering from back pain, neck pain and even Bell's Palsy.  Check out this video:

http://youtu.be/BmzQV3nOudA

Giving Back...

Talk about giving back! Kevin Spencer was in a near death accident years ago and spent a great deal of time in therapy. When he came out, he realized that he could teach "magic" to Physical and Occupational Therapists to incorporate into treatments for patients of all ages. Children who rarely participated in prior therapy sessions could not contain their excitement when learning to do these tricks. And while learning the tricks, they worked on improving motor skill development.  Great continuing education course to take if offered in your area.  Check it out:

MAGIC THERAPY

KB Fitness Post Rehab Circuit: www.facebook.com/kbfitnessllc

This round is 2 minutes long, 30 seconds of each of the following exercises, repeated twice:

Tactical Lunge:
This exercise focuses on strengthening your legs in a functional movement patter, while working your grip, scapula stability and postural musculature to maintain proper form and upright positioning, foot speed and placement, hand coordination and timing and trunk stabilization

Shield Squat Press:
Due to the awkward shape and weight distribution, the shield focuses on trunk/lower back stabilization (in the low squat position, the shield pulls you forward, forcing you to distribute your weight on your heels...proper squat and lower back protection), shoulder stability (in order to control the shield movement), grip strength and the functional squat pattern as well as general shoulder strength for overhead lifting

Click Here:

Round 9

KB Fitness Post Rehab Circuit RD 8

Round 8:
First exercise is Persian Mil Drumming.  In this exercise, you must maintain your shoulders and scapula in their proper position (Correct Posture) in order to effectively train your shoulder/scapula stabilizers for strength and endurance.  The shoulders are held in proper position statically while the arms move the mil (dynamically).  This also works your grip and forearm strength and endurance.
Second exercise uses the Persian Mil again, this time for the Shield Activity.  Your shoulder is a ball and socket joint and the most unstable joint in the body.  You must train it throughout the entire available range of motion in order to stabilize and strengthen it to its potential.  You are moving the Mil using a circular blocking technique.  This not only works your shoulder mobility and stability but also strengthens your grip and forearms.  Combine these two exercises in a 2 minute circuit, and your foreamrs will be toast!

Here it is:

ROUND 8

KB Fitness Post Rehab Circuit RD 7

Round 7:

Mil Lateral Thrust: This exercise will work your grip strength, shoulder stabilizers and help with weight distribution and transfer from one foot to the other

Shield Lunge Curl: This exercise works many of your joints, which will ramp up your heart rate.  You will work your grip, shoulder stabilizers, postural muscles, and lower extremity strength and stability

click below:
ROUND 7

KB Fitness Post Rehab Circuit RD 6

Round 6 consists of the Side Plank with the Nabard Short Device Rear Delt Raise followed by the Nabard Shield Torso Rotation.
The Side Plank works on Core Stabilization particularly engaging the obliques while performing a Scapular Retraction exercise, which is great for postural muscles.  Here, you are stabilizing your body weight on 1 arm using core and shoulder stabilizers, while actively working the Rear Delts on the opposite side.
The Shield Trunk Rotation works grip, shoulder stability, trunk rotational strength while weight shifting from 1 leg to the other.

Here it is:   Round 6

KB Fitness Post Rehab Circuit RD 5

Round 5 consists of the Kettlebell Snatch followed by the Nabard Shield Low to High Diagonal Lift.  The Kettlebell Snatch is great for grip, shoulder flexibility, hip drive and explosiveness, glute strength, core stability.  The Nabard Shield Diagonal uses a PNF Pattern for the entire body, focusing on foot positioning, lunging, core and shoulder stabilization, rotational trunk stability, grip and shoulder flexibility, as well as "grooves" proper body mechanics for lifting from the floor to the chest to the overhead position.  Here it is:

  KB Fitness Round 5

KB Fitness Post Rehab Circuit RD 4: www.facebook.com/kbfitnessllc

Round 4  gets you down to the floor and focuses mainly on the core/trunk stabilizers, but also incorporates shoulder flexibility and stability, grip strength, hip and lower back flexibility, and chest strength.  As always, it's a full body circuit, great for fitness and post rehab fitness for those recovering from upper body and lower back impairments.  Check it out:

http://youtu.be/eKaKPhm73BY

KB Fitness Post Rehab Circuit RD 3: www.facebook.com/kbfitnessllc

Round 3 (sorry, video says round 2 again) has you perform the Kettlebell Squat with curl/shoulder press/French Press for 30 seconds, followed by the Persian Mil Scapula Squeeze.  This circuit is great for leg strength as well as biceps, shoulder, triceps and grip.  The Mil Scap Squeeze also works your grip, and you are required to externally rotate the shoulders, squeezing the scapula together, which will strengthen and improve your postural muscles.

http://youtu.be/gbj8u8MOwms

KB Fitness: Post Rehab Fitness Circuit Round 2

Round 2 consists of the Nabard Long Log Reverse Kayak followed by the Nabard Shield Low to High Diagonals.  These 2 exercises focus on diagonal patterns for the trunk and upper body.  Grip strength, explosive power, shoulder stability and trunk rotational stability are emphasized.  Great for clients in the post rehab stages for lower back and/or shoulder strengthening. 

Click Below...

KB Fitness Post Rehab Circuit Round 2

KB Fitness Post Rehab Circuit Round 1

This full body 2 minute circuit uses a kettlebell and mil device to focus on grip, endurance, explosive power, shoulder flexibility, postural muscles, glute strength, quad and hamstring strength, and psoas (hip flexor) flexibility.  All of this is very helpful in improving overall function, as well as maximizing athletic performance.  Great for Post Rehab Fitness Clients!

http://youtu.be/b-v3j_ZY9YQ

SHIELD TRAINING

 The shoulder joint is the most unstable joint in the human body. It is a ball and socket joint, and has the freedom to move in multiple planes.  With that in mind, we need to strengthen it throughout as much of the available range of motion as possible in order to prevent injuries and maximize athletic performance.  "A chain is only as strong as its weakest link."  Our shoulder joint has primary movers such as the deltoid muscles, and the stabilizers or rotator cuff muscles.  Many times, the rotator cuff is the "weak link."  Repetitive activity will usually bring out these weak links, especially if the activity is performed with poor mechanics and posture.  This may present itself as rotator cuff tendinitis, bursitis or impingement.  Without correcting this, a major injury may occur.  We must work to strengthen and teach the shoulder stabilizers to remain engaged throughout all motions, all angles and positions, especially in sports such as MMA in which our bodies may be placed in awkward positions.  Going to the gym to perform the traditional exercises such as Military press is a start, but with poor stability in the shoulder joint, this will not be enough.  Using a dumbbell which has the weight perfectly balanced and centered in your palm is not always the best choice for stability training either.  Most everyday functional tasks and athletic requirements deal with handling clumsy weights, which must be balanced while trying to perform some other activity, such as walking, running, squatting or lunging.  You are not sliding this weight along a predetermined path like you do with most gym machines, but are working to prevent the object from falling forward or backward while keeping it over head and moving the rest of your body in some other direction.  Many of the 'instability' related injuries not only occur in sports but also at work.

This picture is a pretty good depiction of positions many workers may find themselves in on a daily basis (not exactly as controlled of a situation as using a dumbbell or Smith Machine in the gym).  To summarize, if you want to maximize your strength and abilities for as many possible functional movements as possible, you need to focus on the stabilizer muscles as well as the primary movers of a joint.  You must focus on Stability throughout the entire Mobility of your joints. 

The Nabard Combat Fitness Tools were developed keeping this concept in mind by incorporating an "offset handle" to its design.  I was lucky enough to train with Nabard founder Marco Safakhoo

a few years ago and just recently began training with his newly released Nabard Shield.  It provides amazing results, particularly for joint stability and strength.  As a Physical Therapist, this is a great tool for Post Rehab Fitness, and many athletes should definitely consider incorporating it into their routines in order to prevent injury and take their strength training to the next level.   

CHECK OUT THE VIDEO TO SEE WHAT NABARD SHIELD TRAINING IS ALL ABOUT!!!  http://youtu.be/K2xX-_sH1XQ

This Will Come In Handy!!

For those of you who have a family member, friend, or maybe even you are having difficulty getting in and out of your car due to weakness of the legs, this product may be very beneficial for you.   It is called the Handy Bar and can be purchased at http://www.activeforever.com for less than $25. I have purchased this and used it with many of my patients and they love it. It gives them a sturdy handle to push off of when trying to transfer out of their car.  This will help reduce their fear of falling and provide them with more independence when leaving their home. 

Avoid Tunnel Vision

Many times, I will see a client who complains of knee pain.  During my initial assessment, I will check the knee strength and range of motion.  I will perform special tests to detect deficits with the ACL, PCL, Collateral Ligaments, Menisci, etc.  I will compare the "good" knee to the "bad" one with the prior tests and measures.  That would be considered a "FAIR" assessment.  But to provide a "GOOD" assessment, I must perform a 'peripheral joint scan' checking at least one joint above and one joint below the "problem" area to truly pinpoint the problem.  The knee pain could be caused by some biomechanical problem at the ankle such as over pronation due to tight gastrocnemius, tight soleus or restricted subtalar joint.  It could also be caused by weak hip musculature, particularly the posterior gluteus medius.  You may not pick up on these other areas as being potential causes until 2 or 3 sessions have gone by.  But the point is, do not have tunnel vision.  If your client attends 2 weeks of sessions, and there has been no change in the symptoms, that is your cue to look elsewhere as a possible cause.  Check one joint above and one joint below the knee.  You can usually detect signs of deficiency in these other joints while simply observing your client's posture, gait and stepping activities.  So always pay close attention to your client's movements, especially as they transition from one exercise or position to the next.  You will be surprised at what you see, as it may be the cause of their main complaint.

Proof That Your Client is Progressing

When dealing with a client (or patient) who has been experiencing chronic pain, particularly lower back pain, they often become discouraged at the somewhat slow progress when working towards their goals.  The first thing you want to do is the obvious...make sure they are doing what they are supposed to be doing when they are not working with you (They should be compliant with a home exercise program on a daily basis).  So that you can make educated observations on your client's progress, you should begin with a detailed initial assessment with Objective and Subjective information.  Each session, you should be writing notes not only on what exercises your client is performing, but range of motion and strength measurements, observations on quality of movement, and quantity of work performed before rest is required (Endurance or Activity Tolerance).  This is the information that you will need to show the client many times to carry them along, minimizing discouragement and depression.  So many times, I am working with a client recovering from lower back pain and I hear "my pain has not changed at all since we started."  I explain that this is common.  As they make progress in their rehab sessions, they are able to perform more work outside of the clinic.  More work outside of the clinic is just like performing more exercise or new exercise in the gym.  This causes an increase in soreness.  When I look through the chronological notes with the client/patient, my explanation usually sounds like this..."When we first started, you felt 5/10 (pain score 5 on a scale from 0-10) when getting out of bed in the morning and were unable to perform any additional activities throughout the day without the pain increasing to a 7 out of 10 on the pain scale.  Now, you are exercising daily, cleaning your house, you have returned to work and your pain level is 5 out of 10.  That's progress!!!"  Progress is not a 'black or white' situation.  It is usually slow and steady.  Explain this to your clients and open their eyes to what other details they need to be focused on in order to truly assess their own progress.  Take their minds off "pain, pain, pain," and show them the other aspects which they have made improvements in.  Your clients are looking to you for support and guidance.  They are trusting you with their health and wellness.  Give them as much information on their progress as you can.  Don't just spit out a bunch of weight and rep numbers to show them that they have improved. That information does not mean much in terms of overall functional abilities.  Keep detailed records.  Many times, clients are selective in what they remember, especially when they are  not progressing as quickly as they would like to.  Show them they are not wasting their time.

Organize Your Sessions For Efficiency

When studying to be a Physical Therapist, my practical exams were not just based on my techniques, but the order in which I performed them.  For example, when evaluating or treating a patient with lower back pain, there are certain Special Tests I would like to do in order to help diagnose my patient's condition.  Some of these tests are performed standing, others in sitting, a few with the patient on his/her back, side or stomach.  The last thing a client with back pain is going to want to do is to constantly change positions from one side to the other, sitting to standing to sitting again, etc... So in our practical exams, we had to not only know how to perform the tests, but had to strategically minimize our patient's transitions from one position to the next, minimizing their pain.  You want your patient/client to return for treatment, not leave thinking they are in more pain now than they were before they came to you.  This takes some planning.  In the personal training realm, you may not have clients that are in such acute pain, but many of them are not in the best physical shape and do have difficulty transitioning from one position to the next.  With that in mind, think through each session.  Customize it not only in terms of what exercises you will have your client do, but in which order they will do them.  Try to group as many supine exercises, sitting exercises, standing exercises, etc.. together.  You do not want them to be exhausted before they even attempt the exercise, because they had such a hard time getting into position to do that exercise.  Simple organization will help your sessions run smoothly and efficiently.

"The Good Go To Heaven, The Bad Go To Hell"

When working with a client status post hip, knee or ankle surgery, we must ensure that they will be safe when they are moving around in their home.  Many people have stairs that they will need to navigate to enter or exit their home or to move from one floor to the next.  Initially, they may have too much pain when fully weight-bearing on the surgical leg.  So we use the saying "The Good Go To Heaven, and The Bad Go To Hell" in order to explain that the "good" or stronger leg goes up first upon ascending the stairs, while the "Bad" or weaker leg goes down first, upon descending the stairs.  Basically, the stronger leg is in control of the body weight completely when ascending as well as descending the stairs.  It does the work of controlling the body safely up and down while the weaker, surgical leg goes along for the ride.  Many patients/clients receive home care treatments immediately following their surgery and may receive therapy for up to 2 months.  I have seen these patients many times towards the end of their 2 months, and when I ask them to show me how they climb stairs, they continue to perform the task with "The Good Go To Heaven, and The Bad Go To Hell" strategy.  I think many times, as therapists, we get so caught up in educating a patient to perform this task the safest way possible, that we never progress them to the next step.  As therapists, it should be our goal to get our patient/client as close to their prior activity level as safely possible.  There is nothing wrong with being safe, and advising our patients to perform stair-climbing this way.  However, when they no longer have us by their side, what happens if they accidentally forget and try to go up or down the stairs using the weaker leg to control their body weight?  They never practiced the technique this way while we were with them because we were so intent on doing it the "safest way."  We actually limited their functional improvment by 'protecting' them so much.  In general, the #1 most important thing is to be safe.  But we also want to challenge, progress and move forward.  If your patient/client independently climbs stairs using the "Good go, Bad go" rule, begin strengthening the surgical leg in the same manner so that they are symmetrical, safe and confident if they ever need to use it (Do this as long as their doctor allows full weight bearing on the surgical leg, of course).  Remember, if they didn't have to think about it before, you do not want them to have to think about it now.  Do not fall into the routine of doing the same treatment day in and day out.  Challenge your patient/client and take them to the next level.

Osteoporosis: Wolff's Law

As defined in Wikipedia, Wolff's law is a theory developed by the German Anatomist/Surgeon Julius Wolff (1836–1902) in the 19th century that states that bone in a healthy person or animal will adapt to the loads it is placed under.^[1] If loading on a particular bone increases, the bone will remodel itself over time to become stronger to resist that sort of loading. The internal architecture of the trabeculae undergoes adaptive changes, followed by secondary changes to the external cortical portion of the bone,^[2] perhaps becoming thicker as a result. The converse is true as well: if the loading on a bone decreases, the bone will become weaker due to turnover, it is less metabolically costly to maintain and there is no stimulus for continued remodeling that is required to maintain bone mass.<sup>[3(See Wikipedia Wolff's Law)

Basically, this means that resistive training will help to "strengthen" and improve bone density.  Therefore, if you have a client with the diagonsis of osteoporosis, you need to incorporate strength training, especially in  upright functional positions in order to assist the recovery from, as well as reduce their chance of fractures.  See prior postings for exercises that should be avoided with client's who have osteoporosis.  So if your client with osteoporosis seems hesitant to train with you, now you can explain the benefits to them.</sup>

Osteoporosis & Posture

Osteoporosis, or loss of bone density, may lead to "brittle bones" and fractures, particularly in the spine, hips, and pelvis.  When the vertebrae are affected, 'wedging' of the anterior portion of the spinal bones may occur, which leads to a flexed or kyphotic posture.  With a rounded trunk, you will also see protracted shoulders, and a forward head posture, with excessive capital (head) extension.  Just by observing someone, you will have multiple treatment ideas. 

First and most importantly is to correct their posture by stretching the short, tight muscles and strengthening the stretched out weaker muscles.  Lets start at the head and neck.  With a forward head posture, you will have weak capital (head) flexors, and tight capital extensors.  To counteract this, teach your client chin tucks.  This will stretch the tight suboccipitals while strengthening the capital/head flexors.  It will also realign your ear with your acromion on both sides. 
Now for the shoulders and Scapulae.  We need to stretch our pectorals which have been tightened due to the constant protraction of the shoulders.  The posterior muscles have been stretched out and are weak due to this protracted posture, so you will need to work the retractors such as the rhomboids, rear delts and middle traps..."Bring those shoulders back!"

Most likely there will be a flat lower back, with loss of the lordotic curve.  Pelvic tilts are helpful to reintroduce flexibility and motion to this region.  you will also want to incorporate core stability training to your client, progressing from static to dynamic postures.  Focus on glute training with bridges and glute sets, as the glutes assist in lower back stabilization. 

Integrating the above techniques into each of your client's sessions will help them to correct their current posture, prevent any future injuries and impove their overall results, as it enhances efficiency of all movement.  Once you have corrected posture, then you can move into body mechanics and training movement patterns. 

Osteoporosis: Gym Machines to Avoid

Many women are diagnosed with osteoporosis, which is basically loss of bone density.  With "weak bones," there are a few movements and machines that you should avoid using in the gym, because they place excessive strain on certain bones of the body.  First, the seated hip abductor machine may apply too much stress on the hips/femurs.  This may actually create femur or hip fractures, resulting in a total hip replacement.  The crunch machine as well as the seated trunk extension machine may cause spinal fractures due to vertebral shearing anterior/posterior upon muscle contraction.  Lastly, the seated row machine, especially without chest support may cause compression/spinal fractures.  So if you are working with a client with the diagnosis of Osteoporosis, beware of these machines.  Use your imagination and find other ways to work these hip and trunk muscles.

Simple Technique To Help Improve Posture

Almost all of my patients who come to me with neck pain and headaches require some sort of postural education and retraining.  Many of them work on a computer 8 hours a day for their job.  They feel relief from their symptoms following a therapy session.  However, after working for a day or two, the symptoms return.  When I am discussing this with them, I am always observing their posture.  Most of them revert back to the "slumped over" position in their chair.  Training your posture is not a '3 sets of 15 reps' type of training.  Yes, seated rows do work the scapular retractors which are very important for maintaining correct posture.  Unfortunately, many times you will notice someone performing the rows with great posture, and when they finish their set and stand up to walk over to the next exercise, they have that forward head posture with protracted shoulders again ("slumped").  Postural muscles need to have great endurance.  They must 'hold you' in proper alignment all day long to prevent injuries.  Basically, maintaining proper posture is an isometric exercise.  When retraining posture, you are creating new habits.  Initially, you will feel the medial scapula muscles burning and aching as you focus on holding proper posture.  Because of this, you will go back to your comfort position (protracted scapula and slumping).  You need to be constantly reminded to correct your posture.  One easy way to do this, especially for those of you who work long hours on the computer, is to tape a post-it to the monitor screen.  Write the word "POSTURE" on the post-it.  Everytime you look at the monitor, you will be reminded to correct yourself.  90% of the time when you first start this, you will catch yourself slumping.  Do this long enough and the new habit will take over.  Your proper, upright posture will become your new comfort zone, while the slumped posture will become uncomfortable.  Give it a try!

Too much tactile cueing may not be good

I have spoken of the importance of using tactile cues in order to get a particular muscle contraction or movement to occur.  However, continuing from the previous entry, when dealing with older clients/patients, sometimes too much manual cues may be detrimental.  When you are performing the higher risk exercises mentioned before (standing exercises without support), you are trying to build your patient's self-confidence --- SELF- Confidence.  They must rely on THEMSELVES.  You are there to perform a job, and usually can only work with your patient for a limited time, so you really want them to be safe when you are not there.  Having them walk or perform exercises with your hand on them for security purposes, when they do not really need that much assistance, provides a false sense of security.  When you are not there, they do not feel your support, so their self-confidence may be greatly diminished.  If they do not need it, do not provide it.  I feel the same way about gait belts.  Many therapists use gait belts no matter what.  Usually, a clinic or hospital makes it protocol for liability purposes.  But when the patient is discharged, they will be walking on their own without that gait belt -- without that sense of security.  Use common sense.  If your patient needs the assistance, provide only what they need.  Do not over-assist because you will be under-rehabilitating.  Sometimes you are causing more harm than good by training your patient in an overprotected environment.

Allow Self-Corrections

Many times I will be performing balance training with a patient and he will lose his balance slightly, frequently falling backward.  As I am by his side, I am able to prevent him from falling.  But instead of preventing the fall and completely bringing him to his upright posture, I tell him to "fix it."  As I physically support him, I ask him to maneuver himself back to his stable upright position.  This forces him to use the ankle, hip, core musculature to regain his center of gravity over his base of support.  This is used as an exercise as well as a motor development skill.  If we can get him to regain his balance by synchronizing all the necessary muscles, we are hoping he will incorporate this same technique the next time he feels himself falling backward, thereby correcting it.  So my advice is: Let them make mistakes, be there to protect them and prevent injury, but allow them to attempt corrections on their own.   Let them figure out the solutions and this will enhance their motor planning abilities.

Small Adjustments Produce Big Changes

As a Physical Therapist, I treat many deconditioned patients in their home.  Most of these patients suffer from generalized weakness, balance deficits and difficulty walking.  Initially, depending on the extent of their weakness, I may start them with seated or supine (lying down on their back) exercises.  They then progress to standing exercises, usually holding onto their kitchen sink.  These exercises include heel raises, marching, squats, etc.  We use the sink because it is a stable surface that will not move while the patient holds onto it for balance.  Most of these patients have a fear of falling due to poor balance.  As time goes on, they begin to have less trouble with these standing sink exercises.  However, what is the true functional value of these exercises?  If your patient's goal is to walk without a cane or walker, they are definitiely not going to be walking while holding onto a sink, right?  So how do we get them ready to be independent with their daily activities?

One small adjustment to their position during your sessions will make a big change in their confidence, strength, balance and walking ability.  Have them step back away from the sink, into the middle of their kitchen, with nothing else at arm's reach except for you.  Make sure you remain close to them, but only place your hands on them to prevent a fall.  Now have them perform the same standing exercises that they did when they held onto the sink.  They will seem very cautious, almost fearful.  Progress slowly with this.  Perform only a few reps of each exercise.  This is a confidence building exercise as well as balance and strength building.  They will feel a much greater challenge due to the mental aspect.  The difference here is the risk or fear factor.  They no longer have their security blanket, the kitchen sink.  They must rely on their own abilities (as well as your ability not to let them get injured).  Once they accomplish these tasks over numerous sessions, you will see improvement in confidence, strength, balance and walking ability.  You will see that one minor change can have a very beneficial effect on your patient's progress.  Remember, you are not just training their body, you are also working on their mind.  Take away their "crutch" to get them to the next level.

Functional Training & Observation Skills

We have all heard of Functional Training.  Many of us think of High Intensity Training using Kettlebells, Sandbags, Suspension Training, but it does not stop there.  That may be beneficial for an athlete to maximize his/her performance.  However, what about clients in their 50s, 60s or older, who are looking to improve their quality of life, not their athletic performance?  How do we incorporate Functional Training into their life? 

Just like any of your other clients, find out what their goals are upon the initial evaluation.  For example, presently I have a patient who is recovering from a fractured femur.  She had corrective surgery and during her first session, she stated how happy she would be if she could get down into the bath tub again.  My first goal is to improve her 'quality of life' by helping her return to her prior functional level.  I need to get her to be able to take a bath again.  Initially, if she is having trouble with the basics, such as getting up and down from a chair or is unsteady when walking, I will need to give her a standard strength and balance program (for her legs especially).  I will also need to assess her bathroom, including the size of the tub and the direction of the faucet controls so that I can make the transfer as efficient as possible.

Now here is where the task observation comes into play.  In order for her to transfer safely into the tub I need to break the entire task down into its individual parts, and focus on each part prior to attempting the entire task.  First, she needs to be able to approach the tub, and lift each leg high enough to get into the tub.  Then she needs to be able to transfer into a lunge, then tall kneeling, side-sitting, and sitting with legs stretched in front of her.  To get out of the tub she will need to roll over into quadruped (on hands and knees), into tall kneeling, lunging, standing and finally lift each leg high enough to get out of the tub safely. 

Who would have thought it took so much work to get in and out of the bath tub?  Each session, I work on these individual components, and will eventually take her into her bathroom in order to practice the entire task. 

Your goal is to be observant of the task at hand.  Learn your client's strengths and weaknesses and customize the task to their abilities.  Break down the activity that your client is trying to relearn into its component parts, which will be easier for your client to initially learn and master.   Then, for proper carryover, you need to have your client perform as many of the individual components in proper order as soon as possible, so that it makes sense to your client why she is performing all these exercises/activities.  

Repetition of the task will establish motor patterns in the brain. And before you know it, your goal will be accomplished.   Remember, if you must break the task down into component parts, the trick is to 'bring it all together' as soon as safely possible for actual learning and retention to occur.